Medina Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Durand, Illinois.
- Location
- 402 South Center Street, Durand, Illinois 61024
- CMS Provider Number
- 145495
- Inspections on file
- 29
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Medina Nursing Center during CMS and state inspections, most recent first.
A resident with dementia and multiple comorbidities, care planned as a fall risk with a sensor pad alarm when unattended in bed or chair, experienced two falls in which the personal alarm did not sound. In both events, staff found the resident on the floor and later determined the alarm was not working until batteries were replaced and, in one case, a worn wire was adjusted. CNAs reported that low-battery warning behaviors were known and that repeatedly resetting alarms could lead to dead batteries without staff awareness. The ADON was unaware of the two alarm-related falls, and the resident’s fall care plan was not reviewed or revised to reflect these actual falls or any additional fall-prevention interventions.
A resident with severe cognitive impairment and multiple comorbidities sustained a second-degree burn to the knee after coming into contact with a radiator heating unit positioned directly next to the bed. Staff found the resident's knee resting on the heater, which had a surface temperature of 126°F. The bed was routinely placed very close to the heater, creating an accident hazard that was not addressed prior to the incident.
A resident who was cognitively intact experienced verbal abuse when a CNA, while assisting with morning care, used loud, vulgar, and offensive language during a phone conversation in the resident's presence. The resident felt intimidated and reported the incident, which was substantiated through staff interviews and facility investigation.
A dependent resident with significant medical conditions was left outside in the sun for two hours without water or a way to call for help, due to staff failing to provide required supervision and monitoring. The resident was found unresponsive, suffering from heat exhaustion, sunburn, hypoxia, and altered mental status, and required hospitalization. Staff interviews revealed confusion about responsibility for monitoring and a lack of communication, with the resident unable to signal for assistance or access hydration.
A resident with severe cognitive impairment and multiple health issues was subjected to verbal abuse by a CNA, who used explicit and derogatory language in the resident's presence. The incident was witnessed by another CNA, who reported the behavior to the ADON after leaving her shift early due to discomfort. Facility records and surveillance footage confirmed the occurrence of verbal abuse, in violation of facility policy.
A resident with severe cognitive impairment was subjected to verbal abuse by a CNA, which was witnessed by another CNA on her first day. The witnessing CNA did not immediately report the incident as required by facility policy, instead notifying the ADON later via text. Documentation and interviews confirmed a delay in reporting the abuse allegation.
A resident with multiple medical conditions and who was cognitively intact reported $80 missing from her purse after a visitor, identified as another resident's family member, entered her room multiple times without a valid reason. Video surveillance and staff interviews confirmed the unauthorized entries and substantiated the theft, which was classified as misappropriation of resident property and abuse.
A resident with dementia and severe agitation, identified as a high elopement risk and equipped with a departure alert system, was able to leave the facility unsupervised after the alarm system failed to activate. Staff were aware of the resident's exit-seeking behavior but did not increase supervision, and a caregiver from a neighboring building transported the resident offsite without notifying facility staff.
A CNA observed significant bruising on a resident's arm, wrist, and hand during morning care but did not report it immediately, only notifying the Social Services Director later in the day. Facility policy requires immediate reporting of injuries of unknown origin, such as bruises.
A resident with significant muscle weakness and chronic pain, who requires one-person assistance and a gait belt for transfers, sustained a large bruise on her forearm after a CNA pulled her by the arm during a nighttime transfer instead of using the gait belt as required by her care plan and facility policy. Staff interviews and the resident's account confirmed that proper transfer procedures were not followed, resulting in injury.
Surveyors found that food items in the kitchen refrigerator, including deli meats and potato salad, were not labeled with open or use by dates, and some items were past their use by date or were personal staff food stored with resident food. The dietary manager confirmed these items should have been discarded and that facility policy requires proper labeling and disposal of improperly stored food.
A resident with multiple medical conditions was provided with a pommel cushion and non-slip fabric in a reclining wheelchair to prevent sliding and falls, but staff failed to assess the need for the device, obtain a physician's order, or document its use in the care plan. The DON was unaware of the intervention, and facility policy requiring assessment, consent, and orders for physical restraints was not followed.
Surveyors found that two residents had insulin vials in use for over 30 days and an insulin pen without an open date label, contrary to facility policy and manufacturer guidelines. A registered nurse confirmed that insulin should be labeled with the date opened and discarded after 27 days.
A resident who was eligible for a PCV20 pneumococcal vaccine was not documented as being offered or having consented or refused the vaccine, despite facility policy requiring annual vaccine offers and documentation of resident wishes.
A resident with shingles was not consistently managed under appropriate infection control measures. Despite being on contact precautions, visitors and staff entered the room without PPE, and there was no PPE available outside the room. The facility's policy required contact precautions until lesions were crusted or healed, but this was not consistently followed, leading to a deficiency in infection control practices.
Two residents were involved in incidents due to improper transfer practices. One resident was hit in the face by a mechanical lift when a CNA mistakenly pulled the emergency release. Another resident fell and hit her head during a transfer without a gait belt, despite it being required in her care plan. The facility's policies emphasize the use of mechanical lifts and gait belts for safe transfers.
A resident sustained a forehead laceration due to improper use of a mechanical sling lift by two CNAs. The lift tilted during a transfer, causing a bolt to injure the resident's head. The facility's policy requires one staff to manage the lift and another to support the resident, but this was not adhered to, resulting in the incident.
Failure to Maintain Functional Personal Alarm and Update Fall Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s personal alarm was functioning despite the resident being identified as at risk for falls. The resident had multiple medical conditions, including dementia, congestive heart failure, asthma, type 2 diabetes mellitus, dysthymic disorder, chronic kidney disease, arthropathy, benign prostatic hyperplasia, hypercholesterolemia, gastroesophageal reflux disease, obstructive sleep apnea, hyperparathyroidism, peripheral vascular disease, and hypertension. His care plan, dated 12/8/25, identified him as at risk for falls and required a sensor pad alarm to be in place when he was left unattended in bed, a chair, or a wheelchair. On 1/10/26, the resident experienced an unwitnessed fall in the bathroom; he was found on the floor in a supine position, unable to state what happened, and his alarm was noted to be not working. A CNA reported that the same alarm device was moved between the resident’s bed and chair and that he always had an alarm to alert staff when he tried to get up, as he liked to attempt getting up on his own and fell. An RN stated that on the date of the fall the alarm was not working, and that after she and a CNA replaced the batteries and manipulated the worn wire, the alarm started working. A second fall occurred on 1/23/26, when the resident was found on the floor with his back against his room door, leaning on his right elbow with his legs stretched out, and again his alarm did not sound. The resident stated he was going to the bathroom. A CNA who worked that shift reported that the nurse found the resident on the floor and that the alarm was not going off until the batteries were replaced. The CNA also stated that staff can tell when alarm batteries are going low because some alarms start beeping rapidly or make a humming noise, and that if staff keep resetting the alarm when this happens, the batteries will die and staff will not be aware. The Assistant Director of Nursing stated she was not aware that the resident had two falls in which it was documented that his alarm was not working, and confirmed that the alarm should be working because it is an intervention for falls. The resident’s care plan, dated 12/8/25, was not reviewed or revised to reflect the two actual falls in January 2026 or any changes made for fall prevention, despite the facility’s fall policy stating that residents are to be assessed and fall situations evaluated to identify risk factors and develop individualized interventions.
Resident Burn Injury Due to Bed Placement Near Heater
Penalty
Summary
A dependent resident with severe cognitive impairment and multiple medical diagnoses, including dementia and congestive heart failure, sustained a second-degree burn to his left knee while in bed. The resident was assessed as being at moderate risk for skin breakdown and was dependent on staff for all care. The incident occurred when the resident's knee came into contact with a metal radiator heating unit located directly next to his bed, which was positioned parallel and in close proximity to the heater. The heating unit's surface temperature was recorded at 126 degrees Fahrenheit. Staff interviews and observations revealed that the resident's bed was typically placed very close to the heating unit, with only a small space between the bed and the heater, making it difficult for staff to access the area. On the day of the incident, staff found the resident lying on his side with his knee resting on the heater. The resident did not report pain, but staff observed redness, a popped blister, and serosanguinous drainage on the knee. The resident was known to move himself in bed, sometimes repositioning himself after staff had assisted him. The facility's policy required employees to exercise maximum care and good judgment to prevent accidents and injuries, and to report unsafe conditions. However, the arrangement of the resident's bed in close proximity to a high-temperature heating unit created an accident hazard that was not addressed prior to the incident, resulting in the resident sustaining a burn injury.
Verbal Abuse by CNA During Resident Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) engaged in verbally abusive behavior toward a cognitively intact resident while assisting her with morning care. The CNA entered the resident's room wearing earphones and was loudly conversing on the phone, using vulgar and offensive language, including repeated use of profanities and religious expletives. The resident, who was alert and able to recall the incident, reported feeling confused, intimidated, and personally offended by the language and the CNA's angry tone. She expressed fear of potential retaliation and reported the incident to staff to prevent similar occurrences with other residents. Staff interviews and documentation confirmed that the incident was promptly reported to nursing and social services. The CNA was observed on camera using her phone in the hallway outside the resident's room, though the audio was not captured. The facility's policy defines verbal abuse as the use of disparaging or derogatory language within hearing distance of residents, regardless of their ability to comprehend. The investigation substantiated the resident's account, confirming that the CNA's conduct constituted verbal abuse and failed to provide the resident with the attention and respect required.
Resident Left Unattended Outside Resulting in Hospitalization for Heat-Related Illness
Penalty
Summary
A dependent resident with multiple medical conditions, including rheumatoid arthritis, major depressive disorder, encephalopathy, acute kidney failure, and peripheral vascular disease, was left outside in her reclining wheelchair for two hours without water or a means to call for help. The resident was entirely dependent on staff for all activities of daily living and mobility, as documented in her care plan. On the day of the incident, she was placed directly in the sun after lunch, and staff failed to provide the required supervision and monitoring. Staff interviews revealed that the usual practice was to set a timer for 10-20 minutes when the resident was taken outside, with checks at those intervals due to her inability to signal for assistance or return inside independently. However, on this occasion, there was confusion and lack of communication among staff regarding who was responsible for monitoring the resident and whether a timer had been set. Multiple CNAs stated that the resident did not have water with her and could not hold a drink, and there was no call light or device for her to request help. The resident was not in direct view of the door, and staff were unaware of her presence outside until she was found unresponsive by another CNA. Upon discovery, the resident was unresponsive, with her eyes rolled back and twitching, and was noted to be red, hot, and very thirsty. Immediate interventions included providing water, applying cold compresses, and administering oxygen. She was subsequently transferred to an acute care hospital, where she was treated for heat exhaustion, sunburn, hypoxia, altered mental status, and dehydration. Hospital records confirmed sunburn to her face, neck, and chest, hypoxia, and improvement after IV fluids. The facility's policy required 15-minute checks for residents outside, but this was not followed, resulting in the resident's prolonged exposure and subsequent hospitalization.
Removal Plan
- An assessment form was created and implemented to assess the residents' ability to safely be outside unattended. All residents have a completed assessment for going outside unattended. Newly admitted residents will have a completed assessment for going outside unattended. This assessment will be reviewed if there is any change in condition. Audits will be completed by DON or designee.
- Current policy reviewed. Input from Certified Nursing Assistants (CNAs) was collected via Survey Monkey. Policy updated with feedback from managers and CNAs. The policy includes identifying safety measures and resident assessment, timely checks on the resident and documentation on a log. A timer is placed at the door entry (Door 4) where residents go outside. The log book is stationed at Team B nurses' station, next to Door 4. The log includes documenting time going outside, checks, notes regarding resident, hydration offered, time coming in, and staff signature.
- All managers were educated on the new policy/procedure. Managers then educated their staff. This ensured that staff were educated on the policy and procedure prior to their next shift worked. Agency: New policy & Procedure has been sent to agency organizations who will in turn disseminate to their staff. Agency staff will be educated on arrival by DON or designee.
- Policy states that whoever takes the resident outside is the one responsible to ensure check is conducted. A timer is set to alert for checking on the resident outside. If the CNA is unable to check on resident, CNA must find another CNA to check on the resident. CNA must confirm with other CNA that the check is being conducted, either verbally or over the walkie/talkie. If the CNA is unable to find another individual to do the check, the resident is brought back in to the facility.
- Audits will be conducted by DON or designee.
Verbal Abuse of Cognitively Impaired Resident by CNA
Penalty
Summary
A resident with severe cognitive impairment and multiple medical conditions, including malignant neoplasm of the prostate, acute posthemorrhagic anemia, severe protein calorie malnutrition, depression, hypertension, muscle wasting, and dysphagia, was subjected to verbal abuse by a Certified Nursing Assistant (CNA). The incident occurred when a newly oriented CNA entered the resident's room to assist with a transfer and witnessed another CNA using foul language and derogatory terms toward the resident, including explicit language referencing the resident's status as a veteran. The resident responded by asking for help and expressing that he was not treated well at the facility. The witnessing CNA reported feeling extremely uncomfortable and left her shift early, later notifying the Assistant Director of Nursing (ADON) about the incident. Facility records and interviews confirmed that the abusive language was used in the resident's presence and that the incident was corroborated by surveillance footage. The facility's investigation found sufficient evidence of verbal abuse, as defined by their policy, which prohibits disparaging or derogatory communication toward residents. The incident was reported and documented, and the staff member involved was identified as having violated facility policy regarding resident abuse.
Failure to Immediately Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse was reported immediately for one resident who was severely cognitively impaired and dependent on staff for care. On the first day of work, a CNA witnessed another CNA using foul and derogatory language toward the resident during care, which made the resident visibly distressed and prompted the witnessing CNA to leave her shift early. The CNA reported her concerns to the Assistant Director of Nursing (ADON) later that day via text message, rather than immediately notifying the floor nurse, social services, or other appropriate personnel as required by facility policy. Facility records show that the incident was not reported until several hours after it occurred, despite clear orientation training on abuse reporting procedures. The facility's policy mandates immediate reporting of abuse allegations to nursing, the Administrator, and Social Services to ensure prompt investigation and notification of necessary agencies. The delay in reporting was confirmed through interviews and documentation, and surveillance footage corroborated the account of verbal abuse occurring in the resident's room.
Failure to Protect Resident from Theft by Visitor
Penalty
Summary
A resident, who was cognitively intact and had multiple medical diagnoses including protein-calorie malnutrition, cancer, anxiety, osteoporosis, adult failure to thrive, and major depressive disorder, reported that $80 was stolen from her purse while residing in the facility. The resident stated she had attempted to give the money to her daughter, who refused it, and then placed the money in her wallet, which was kept in her purse hanging on a hook inside her room. The resident discovered the money missing when preparing to go out with friends and immediately reported the theft to staff, who searched her room but could not locate the missing funds. Facility staff initiated an investigation, which included reviewing video surveillance footage. The footage revealed that a visitor, who was the grandson of another resident, entered the resident's room multiple times over a short period. Initially, the visitor was given the wrong room number by a CNA and entered the resident's room by mistake. However, after being directed to the correct room, the visitor returned to the resident's room several more times without a legitimate reason, as confirmed by both staff interviews and video evidence. The visitor was identified by his grandfather and another family member present at the facility. The facility's investigation concluded that the resident was a victim of misappropriation of property, which constitutes abuse. The suspected individual was not affiliated with the facility but was a family member of another resident. The resident expressed embarrassment over the incident and did not wish to press charges. Staff and social services substantiated the theft and classified it as abuse, confirming that the resident's belongings were not adequately protected from wrongful use by visitors.
Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Supervision and Alarm Malfunction
Penalty
Summary
A resident with diagnoses including dementia with severe agitation, anxiety disorder, and hypertension was admitted to the facility and identified as a severe elopement risk. The resident was independent with ambulation and was equipped with a departure alert system on her wrist. Despite these precautions, the resident was able to leave the facility unsupervised and was later found at her daughter's house. The facility's incident investigation revealed that staff became aware of the resident's absence after a CNA questioned her whereabouts over the walkie, prompting a search of the facility and surrounding areas. Interviews with staff indicated that the resident had been displaying exit-seeking behaviors on the morning of the incident, including packing her bags and expressing a desire to go home. Although the DON and nursing staff were aware of her agitation, enhanced supervision such as 1:1 monitoring or frequent checks was not implemented. The departure alert system, which was intended to notify staff if the resident attempted to leave, did not activate when the resident exited the building. Staff had previously checked the system and believed it was functioning, but it failed to alert them during the incident. Further review showed that a caregiver from an adjacent apartment building encountered the resident outside the facility and, after a brief conversation, transported her to her daughter's house without notifying facility staff. The facility's policy required weekly checks of the departure alert system, but staff reported that checks were being done nightly and, after the incident, every shift. The failure to provide adequate supervision and ensure the proper functioning of the departure alert system resulted in the resident's unsupervised exit from the facility.
Failure to Timely Report Resident Bruising
Penalty
Summary
A facility failed to ensure timely reporting of suspected abuse when a certified nursing assistant (CNA) observed a large bruise on a resident's right arm, wrist, and hand during morning care but did not report the finding immediately. The CNA first noticed the bruising at approximately 8:30 AM while assisting the resident with dressing but did not inform anyone at that time due to being busy. The bruising was only reported later in the afternoon to the Social Services Director. According to the facility's policy, injuries of unknown origin, such as bruises, are to be reported immediately to the appropriate personnel.
Improper Transfer Technique Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with diagnoses of weakness, muscle weakness, chronic fatigue, osteoarthritis, and chronic pain was not transferred safely by staff. The resident, who requires one-person assistance and a gait belt for transfers, was found with a large, dark purple/red bruise encircling her right forearm. The resident reported that during a nighttime transfer, a CNA pulled her by the arm to help her out of bed, rather than using the gait belt as required by her care plan. The CNA involved stated it was her first time assisting this resident at night and that she believed the resident could stand with a walker, so she assisted her to stand and then held the gait belt, but did not describe using the gait belt during the initial transfer from bed. Other staff members familiar with the resident confirmed that proper transfer technique involves the use of a gait belt and that the resident should not be pulled by the arms. The facility's policy also requires staff to use gait belts for non-mechanical transfers. The improper handling was corroborated by staff observations and interviews, as well as the resident's own account, which indicated that the transfer was rough but not intentionally abusive. The incident resulted in significant bruising to the resident's forearm.
Failure to Properly Store, Label, and Discard Food Items
Penalty
Summary
Surveyors observed that the facility failed to properly manage food storage and labeling in the kitchen. During a kitchen tour, an open bag of turkey breast and an open bag of ham were found in the refrigerator without any open or use by dates. Additionally, a reusable container labeled with the dietary manager's first name and a date, a metal container of potato salad past its use by date, and a whipped topping container with no labels or dates containing black olives were also found. The dietary manager confirmed that the container with her name was her personal item, was unsure how long the olives had been there, and acknowledged that the deli meats and potato salad should be discarded due to lack of proper dating or being past the use by date. The facility's policy requires all items in the cooler to be labeled with the item, initials, date, and use by date, and any improperly stored food to be disposed of immediately. These failures were identified as having the potential to affect all 46 residents in the facility.
Failure to Assess, Obtain Order, and Document Use of Pommel Cushion
Penalty
Summary
A deficiency occurred when a resident was observed seated in a reclining wheelchair with a pommel cushion and non-slip fabric, without prior assessment of the need for this device. The Certified Nursing Assistant (CNA) stated that the cushion was used to prevent the resident from sliding forward and falling out of the chair. The Director of Nursing (DON) was unaware of the cushion's use and confirmed that it was not included in the resident's care plan. The restorative aide reportedly added the cushion due to the resident's seizure disorder and tendency to scoot down in the chair, and the hospice nurse was aware of its use. However, there was no documentation of a physician's order for the cushion, nor was its use reflected in the care plan. The resident in question had multiple diagnoses, including epilepsy, pseudobulbar affect, delusional disorder, abnormal breathing, sleep apnea, hypothyroidism, Down syndrome, pain disorder, and depression. The care plan noted the resident's risk for falls and her behavior of sliding or scooting forward in her wheelchair, but did not include any interventions related to the pommel cushion. The facility's policy defined physical restraints and required that their use be preceded by less restrictive alternatives, informed consent, and a physician's order, none of which were documented in this case.
Failure to Properly Label and Discard Expired Insulin
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and timely disposal of insulin for two residents. During inspection of the medication storage cart, one resident's lispro insulin vial and another resident's novolog insulin vial were both found to be opened and labeled with dates indicating they had been in use for over 30 days, exceeding the facility's policy and manufacturer recommendations for insulin use. Additionally, an opened tresiba insulin pen for the second resident was not labeled with an open date. A registered nurse confirmed that insulin should be labeled with the date opened and discarded after 27 days. Review of physician orders confirmed that these insulins were currently prescribed for the residents. The facility's own policy requires opened insulin to be clearly labeled with the date opened and disposed of after 28 days or per manufacturer instructions.
Failure to Offer and Document Pneumococcal Vaccination Consent
Penalty
Summary
The facility failed to ensure that a resident was offered and/or received the recommended pneumococcal immunization according to current CDC guidelines. The Assistant Director of Nursing/Infection Prevention Nurse stated that vaccines are offered to residents upon admission and annually, including all types of pneumococcal vaccines. Review of the resident's records showed she had previously received PCV-13 and PPV23 vaccines, making her eligible for a dose of PCV20 based on shared clinical decision-making recommendations. However, there was no documentation of consent or refusal for the PCV20 vaccine for this resident. The facility's policy requires that pneumonia vaccines be offered upon admission and annually, with residents or their representatives asked to indicate their wishes regarding the vaccine, but this process was not documented for the resident in question.
Inconsistent Infection Control Practices for Resident with Shingles
Penalty
Summary
The facility failed to implement appropriate infection control interventions for a resident diagnosed with shingles. The resident, who was admitted with multiple diagnoses including Type 2 Diabetes and moderate cognitive impairment, was noted to have clear fluid-filled blisters and was placed on contact precautions. However, inconsistencies were observed in the application of these precautions. On several occasions, the infection notes indicated varying levels of precautions, from standard to contact with cares, and there was a lack of clarity and consistency in the implementation of these precautions. On a specific date, a sign indicating contact precautions was posted on the resident's door, yet visitors and staff were observed entering the room without donning personal protective equipment (PPE). The Director of Nursing and the Infection Preventionist both stated that PPE was only necessary during direct care, contradicting the facility's policy which required contact precautions until lesions were crusted or healed. The facility's policy also specified the need for isolation bins with PPE outside the resident's room, which was not adhered to, leading to a deficiency in infection control practices.
Improper Transfer Practices Lead to Resident Injuries
Penalty
Summary
The facility failed to ensure safe transfer practices for residents, resulting in two incidents involving improper use of equipment and lack of safety measures. In the first incident, a CNA inadvertently pulled the emergency release of a full body mechanical lift while transferring a resident, causing the lift to hit the resident in the face and knock off her glasses. The CNA admitted to pulling the release absentmindedly after dropping the controller, despite there being no emergency. The Director of Nursing confirmed that pulling the emergency release was not standard practice, and the facility's Mechanical Lift Policy emphasized the use of mechanical lifts for safe transfers. In the second incident, a resident fell and hit her head on the toilet during a transfer from the toilet to a wheelchair. The CNA assisting the resident did not use a gait belt, despite the resident's Fall Care Plan indicating its necessity for transfers. The CNA stated she did not use a gait belt for short transfers, although she did use it for bed-to-wheelchair transfers. The Physical Therapist highlighted the importance of gait belts for stabilizing residents and preventing falls. The facility's Gait Belt Policy also underscored the use of gait belts as a safety measure.
Improper Use of Mechanical Sling Lift Causes Resident Injury
Penalty
Summary
The facility failed to safely control a full body mechanical sling lift, resulting in a resident sustaining a laceration to her forehead. The incident involved two Certified Nursing Assistants (CNAs) who were transferring the resident using the mechanical sling lift. During the transfer, the lift tilted, causing a bolt to lacerate the resident's head. The resident was subsequently found with a 5-centimeter wound on her forehead, which appeared to be an abrasion. The resident reported that there were two staff members present during the transfer, and she began bleeding profusely after the incident. The CNAs involved provided conflicting accounts of the incident. One CNA was guiding the resident while the other operated the mechanical lift. The Assistant Director of Nursing (ADON) reported hearing a commotion and found the lift tilted when she entered the room. The CNAs explained that the resident was hooked up on the lift and repositioned in the wheelchair, which caused the lift to tilt. The facility's Mechanical Lift Policy/Procedure requires one staff member to manage the lift while the other supports the resident, ensuring proper positioning over the wheelchair. However, this procedure was not followed, leading to the resident's injury.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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